QuoteGillen Washington, 23, is suing Aetna for breach of contract and bad faith, saying he was denied coverage for [treatment] when he was 19. His suit alleges Aetna's "reckless withholding of benefits almost killed him."

To cut to the chase, denied the expensive, yet indicated treatment, the kid ended up with an even more expensive hospital stay.

QuoteWashington, who was diagnosed with common variable immunodeficiency, or CVID, in high school, [says] that Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that the treatment was medically necessary "to prevent acute and long-term problems."

During his videotaped deposition in October 2016, [Dr. Jay Ken] Iinuma -- who signed the pre-authorization denial -- said he never read Washington's medical records and knew next to nothing about his disorder.

Questioned about Washington's condition, Iinuma said he wasn't sure what the drug of choice would be for people who suffer from his condition.

Iinuma further says he's not sure what the symptoms are for the disorder or what might happen if treatment is suddenly stopped for a patient.

"Do I know what happens?" the doctor said. "Again, I'm not sure. ... I don't treat it."
Iinuma said he never looked at a patient's medical records while at Aetna.

The horrible thing is that I'm sure this doc was just doing the job in the way that Aetna set out - the chart review is done by a nurse, and this doc just signs off on their recommendation from afar on a computer screen. This kind of thing sadly goes on all the time in American medical care.

It's not a cut-and-dried story - Aetna says they just wanted to confirm the diagnosis (again) with a lab test and the patient didn't comply.

But now their ass is in a sling big-time. It's turned over a big rock, and folks aren't going to like what they see beneath.

ANYONE with a chronic condition has dealt with this sort of nearsighted stupidity. The 'evil insurance company' in the film "The Incredibles" is 100% true.

I've experienced it when my insurance refused to cover my chronic asthma treatment, and required me to try a drug that pretty much left me wanting to kill myself. And a refusal to provide physical therapy treatment without an MRI. Biotch, I have stainless steel implants, I CAN NOT have an MRI.

My lovely wife has experienced it.. her neurologist asked for a drug treatment for her fibromyalgia, and our insurance said "No, she has to have spinal surgery first". Mother F*ing WHAT ?

Oh yeah... and these misery panels ? we pay for them with increased health insurance costs.

Other side of the story: why didn't the patient comply with the requests for blood tests from his treating physician? Three years without blood tests with a life-threatening, acute condition? Why didn't he get the infusions that were covered by Aetna? I get that health insurance companies make our lives miserable sometimes - but noncompliance by patients is a very big problem too.

Aetna initially paid for his treatments after each infusion, which can cost up to $20,000. But when Washington's clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says it was obligated to review his medical record. That's when it saw his last blood work had been done three years earlier for Kaiser.
Despite being told by his own doctor's office that he needed to come in for new blood work, Washington failed to do so for several months until he got so sick he ended up in the hospital with a collapsed lung.
Once his blood was tested, Aetna resumed covering his infusions and pre-certified him for a year. Despite that, according to Aetna, Washington continued to miss infusions.
Washington's suit counters that Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that the treatment was medically necessary "to prevent acute and long-term problems."

Well, as I said, it's not a cut-and-dried story. I suspect that he didn't get the blood test because his doc had probably explained to him that this was, unfortunately, a chronic, genetic condition that he would have to live with forever, and get treatments for (as long as he wanted to live).

And then he changed insurance companies and they said, you have to prove to us you have this condition...and that's despite his doc writing letters to Aetna attesting to his condition and treatment needs. Being a 19 year old, in his mind he probably told Aetna to FO and won't you be sorry if I get sick? (just my speculation based on once having had a 19-year-old mind.)

What he did do is rolled over a rock to show us all what lies beneath. Regardless of the facts of the case, I suspect Aetna will regret leading him to do so.

The Phorum Wall keeps us safe from illegal characters and words
The doorstep to the temple of wisdom is the knowledge of one's own ignorance. -Benjamin Franklin
BOYCOTT YOPLAIT [www.noyoplait.com]
[soundcloud.com]

There are a number of issues here that need clarification before judging the degree of obstruction on the part of the insurer versus noncompliance by the patient. First, does this infusion usually require pre-authorization, and why did Aetna pay for the first infusion(s)? I can imagine that Aetna may have paid the first infusion(s) as a "courtesy" to a new customer. If so they might have informed him when they paid the claim(s) that they could allow him a certain number of treatments within a certain period of time as a new customer transferring from another insurer, but that further treatments would require pre-authorization. It wouldn't surprise me to hear that a pre-authorization might require more recent blood work. I have run into analogous issues regarding medications that were categorized one way by one insurer and another by the next.

It would need a detailed timeline of all the correspondence involved in order to evaluate what was really going on.

This is not to say that the insurer is fault-free, but that this case may not be as egregious as it is portrayed.

It is not that Washington didn't give a blood test, or cooperate. The issue is the insurance company doctor admitting, under oath, that his coverage decision was made without ever looking at the patients records. Without looking, that doctor would not even know that the blood tests were missing. It is rather evident that the decision was based on profits not medical needs.

This reminds me of Grisham's "The Rainmaker"

“No persons are more frequently wrong, than those who will not admit they are wrong.”
-- François de La Rochefoucauld